Failure to Set Bed Alarms Resulting in a Fall and Death

The Mellon Case

Case Summary

The hospital’s medical staff failed to properly set multiple bed alarms connected to Mr. Mellon’s bed for his safety, which resulted in Mr. Mellon falling, requiring surgery, and dying from complications related to the surgery. Despite Mr. Mellon being assessed as the highest-level fall risk on numerous occasions during his admission, and despite having two bed alarms, Mr. Mellon was able to get out of bed and walk more than 10-feet across his room, until he fell and broke his hip without any medical staff being alerted or responding. As a result, Mr. Mellon required surgery and died days later from problems related to the injuries sustained from the fall and the subsequent surgery.

Case Details

On May 30, 2019, Mr. Mellon, who was 89 years-old at the time, presented to the hospital with complaints of confusion and hallucinations presumed to be secondary to a urinary tract infection. He had recently been discharged from the same hospital a week earlier following an inpatient admission for a urinary tract infection and delirium. Follow Mr. Mellon’s discharge and completed antibiotic course, his family felt that his delirium had worsened, and he returned to the hospital.

Mr. Mellon had a history of falls and was a fall risk when he was admitted on May 30. He was seen in the Emergency Department, and at 7:38 a.m., he was assessed as a Level 2 fall risk, which is the highest-level fall risk a patient can be labeled. An assessment completed by a nurse at 10:13 a.m. again labeled Mr. Mellon as a Level 2 fall risk, and she began documentation that a bed alarm was being utilized as a fall intervention for Mr. Mellon’s safety.

Mr. Mellon was transferred to the Progressive Care Unit at 11:18 a.m. Another assessment completed by a nurse assessed Mr. Mellon again as a Level 2 fall risk. An assessment was completed by another nurse, Nurse Gallagher, at 9:40 p.m. Nurse Gallagher assessed Mr. Mellon as a Level 2 fall risk and listed a bed alarm as a fall intervention being implemented as well as “heavy assist” out of bed with 1 person assist. A patient care technician documented vital signs at 9:45 p.m., and at 10:21 p.m., she noted fall interventions including bed low, non-slip footwear, personal items close, yellow fall band on, and focus rounding that included pain, toileting, and positioning. However, there was no mention of a bed alarm because, according to her deposition testimony, she did not check the bed alarm at that time.

At 10:40 p.m., a condition C (called when a patient is in crisis and needs rapid evaluation) was called for an unwitnessed fall. Mr. Mellon was reportedly yelling in pain for help before the nursing staff found him sitting on the floor near the restroom, more than ten feet from his hospital bed. Nurse Gallagher testified that the alarm did not work at the time Mr. Mellon was found out of bed. Mr. Mellon had two bed alarms being utilized at the time he was found out of bed; the first is the bed exit alarm that is built into the bed, and the second alarm is a mat alarm called a Posey Alarm. Though Nurse Gallagher testified that both alarms were set, neither alarm alerted medical staff that Mr. Mellon was out of bed, which allowed him to ambulate more than 10-feet from his hospital bed before he fell. Despite Nurse Gallagher alleging that both alarms did not operate properly, work orders completed by engineers who inspected the bed and bed alarms found that neither alarm had any mechanical issues. In fact, one of the engineers found that the bed exit alarm connected to Mr. Mellon’s bed was set to the lowest volume when he inspected the bed. Both the bed exit alarm and the Posey Alarm were serviced after Mr. Mellon was found on the floor, and both were found to be functioning properly with no mechanical issues.

X-rays taken following Mr. Mellon’s fall showed a right intertrochanteric hip fracture. On the morning of May 31, 2019, Mr. Mellon was noted to be confused, delirious, and not answering questions appropriately, and on June 1, 2019, Mr. Mellon underwent a surgery to reposition the right upper femur with an intramedullary internal fixation device (cephalo-medullary nail to the right femur). Despite efforts of his primary team to treat his delirium, Mr. Mellon had a progressive decline, required antipsychotics, and was unable to eat anything.

During the early morning of June 7, 2019, a condition A (called when a patient is in cardiac arrest) was called, and Mr. Mellon was found to be in asystole. CPR was initiated by the nursing staff, and after about 20 minutes of resuscitation efforts, it was determined that Mr. Mellon died at 4:17 a.m. The Death Certificate filled out at the hospital listed the cause of death as acute respiratory failure and intermittent apneic breathing with significant contributing factors listed as UTI, delirium and right hip fracture. The Medical Examiner’s office filled out the official Death Certificate and determined that the immediate cause of death was “blunt force trauma of the right hip” secondary to “fall.”

Mr. Mellon was expected to recover from his UTI and resultant delirium has this event not taken place.

Lawsuit

We filed suit on behalf of Mr. Mellon’s son against the hospital for the failure to implement the proper fall risk interventions, the failure to ensure that both of Mr. Mellon’s bed alarms were on with the volume turned up and functioning properly, and allowing Mr. Mellon to suffer a preventable fall.

The Defense maintained that the use of bed alarms cannot prevent falls and be alarms are ineffective as fall prevention devices, which completely undermines the use of bed alarms on every patient that is assessed as a high-level fall risk. While the Defense stood by Nurse Gallagher’s story that she set both alarms at the beginning of her shift and set them at their highest volume, we had a nursing expert review the case who found it difficult to accept that two separate alarms just happened to malfunction at the same exact time. Given that both alarms were serviced after Mr. Mellon was found on the floor and both were found to be functioning properly, the nursing expert opined that either the alarms were improperly set at the beginning of the shift by Nurse Gallagher, or someone tampered with the volume after the alarms were set. In the alternative, the hospital breached the standard of care by placing Mr. Mellon in a bed with two malfunctioning alarms. While either one of the disturbing reasons for Mr. Mellon’s alarm not going off could have occurred, it does not negate the responsibility of the staff to assure that this patient remained safe under their care. It is the duty of the nurses to protect patients from harm.

A Hospitalist also reviewed this case and determined that the fall suffered by Mr. Mellon significantly increased the risk of his death and reduced his life expectancy. Mr. Mellon’s condition after the fall caused him to experience pain, both in the pre-operative and post-operative setting.

In a hospital setting, physicians rely heavily on the nurses to implement protocols that are used to help mitigate fall risks. One such intervention nurses often utilize is the bed alarm. In this case, it was undisputed that regardless of what caused the bed alarms not to sound, the bed alarms connected to Mr. Mellon’s bed did not sound and alert the medical staff of Mr. Mellon getting out of bed as they were supposed to do. This failure eliminated the ability for medical staff to quickly respond when Mr. Mellon was out of bed and stop him from falling, outside of the small chance that someone just happened to look in his room as he was getting out of the bed.

After deposing the nurses involved in Mr. Mellon’s care, in addition to one of the engineers who inspected Mr. Mellon’s bed and bed alarm, we were prepared to take the case to trial. However, due to the backlog of cases that resulted from the COVID pandemic, Allegheny County attempted to resolve some cases by ordering mediation to be handled by a judge, which is what occurred in this case. A settlement was reached during the court ordered mediation.

Result

Following a mediation, the parties reached an agreement to settle the case for a substantial amount.